Healthcare Provider Details

I. General information

NPI: 1659539203
Provider Name (Legal Business Name): GREAT RIVER COMMUNITY MEDICAL CLINIC SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARQUETTE RD SUITE 106
PRAIRIE DU CHIEN WI
53821
US

IV. Provider business mailing address

100 N MARQUETTE RD SUITE 106
PRAIRIE DU CHIEN WI
53821
US

V. Phone/Fax

Practice location:
  • Phone: 608-326-1072
  • Fax: 608-326-1076
Mailing address:
  • Phone: 608-326-1072
  • Fax: 608-326-1076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23379
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23439
License Number StateWI

VIII. Authorized Official

Name: MARK A GRUNWALD
Title or Position: PRESIDENT
Credential: MD
Phone: 608-326-5459